Liberal glucose targets for critically ill diabetic patients: is it time for large clinical trials with more personalized endpoints?

The field of glycemic control for critical care patients has evolved progressively since the publication of the guidelines for the use of insulin infusions in critically ill patients (1). At that time, the data were inadequate to define an optimal target for insulin therapy, and the committee endorsed the goal to keep glucose less than 10 mmol/L for ICU patients to reduce mortality. This same trigger has been promoted by the ADA (2). While select populations may benefit from tighter levels of glucose control, the need for safety is paramount—avoiding hypoglycemia (<4 mmol/L) and minimization of glucose variability are important for optimal patient outcome. However, a contrary perspective is that hyperglycemia is a marker for stress response and severity of illness, and control of glucose may be detrimental—particularly when attempting to achieve low targets such as 4.4–6.1 mmol/L (3).